A fear hierarchy, also known as a hierarchy of fears or exposure hierarchy, is a tool used in Exposure Response Prevention (ERP) and Cognitive-Behavioral Therapy (CBT) to help individuals with obsessive-compulsive disorder (OCD) gradually confront their fears and anxieties. The hierarchy is a list of situations, objects, or activities that trigger obsessive thoughts and compulsive behaviors, ranked from least to most anxiety-provoking.

Here's how to create an OCD fear hierarchy:

1. Identify Obsessions and Compulsions: Work with a therapist to identify the obsessions and compulsions that are most distressing and interfere with daily life. Examples of obsessions may include fear of contamination, harm to oneself or others, or unwanted sexual thoughts. Compulsions may include excessive cleaning, checking, counting, or repeating rituals.

2. Rank Fears on a Scale: Once you have identified the most distressing obsessions and compulsions, rank them on a scale from 0 to 10 based on the level of anxiety they cause. For example, a fear of contamination from touching a doorknob may be ranked as a 2 on the scale, while a fear of harm to oneself or others may be ranked as a 10.  

3. Define your SUDS: We need to have a scale that captures how much emotional pain you are in and any given point.  The shorthand for these numbers is SUDS (Standard Units of Distress).  Clients of Kairos will get accustomed to getting constantly asked: “What’s your Suds?”  The SUDS is distinct from the ranking of fears, and also may depend on the other factors, such as general mood regulation on any given day.   

4. Create the Hierarchy: Create a list of situations, objects, or activities related to each obsession and compulsion, starting with the least anxiety-provoking and working up to the most anxiety-provoking. For example, if the fear of contamination is the main obsession, the hierarchy may include touching a doorknob, using a public restroom, shaking hands with someone, and so on.We

5. Practice Exposure: Once the hierarchy is created, the individual can begin practicing exposure to the feared situations or objects, starting with the least anxiety-provoking item on the list. The therapist will guide the individual through the exposure, helping them learn coping strategies to manage their anxiety and resist engaging in compulsive behaviors.

6. Gradually Work Up the Hierarchy: Over time, the individual will gradually work up the hierarchy, practicing exposure to increasingly anxiety-provoking items on the list. The goal is to help the individual develop new coping strategies and reduce the power of their obsessive thoughts and compulsive behaviors.

Creating an OCD fear hierarchy is an important step in Exposure Response Prevention (ERP) for OCD.

It helps individuals confront their fears and anxieties in a systematic and gradual way, which can lead to significant improvements in their symptoms and overall quality of life. It's important to work with a trained therapist to create a customized fear hierarchy and receive guidance and support throughout the exposure process.

To learn more about our OCD therapy and ERP, please contact Kairos Wellness Collective today.